Use of general practitioner beds in Leicestershire community hospitals.

BACKGROUND. The shift in care from secondary to primary services is likely to place greater demands on community hospitals. Before changes in the provision of community hospitals can occur, baseline data are needed, outlining their current use. AIM. A study was undertaken to obtain baseline data describing the use of general practitioner beds in Leicestershire community hospitals. METHOD. A three-month prospective, observational study was carried out between February and May 1992 using data from a questionnaire completed by nurses and general practitioners and from patient hospital records. Study patients comprised all patients admitted to general practitioner beds in all eight Leicestershire community hospitals. RESULTS. A 100% questionnaire response rate was obtained giving data on 685 hospital admissions. Around 70% of admissions were of patients aged 75 years and over. Of admissions, 35% were for acute care, 31% for respite care, 22% for rehabilitation, 7% for terminal/palliative care and 5% for other reasons. Fifteen per cent of patients had been transferred from a consultant bed. Of those not transferred, 91% were admitted by their usual general practitioner or practice partner and for 96% of these patients this was the general practitioner's first choice for care. There was significant variation in both the age mix and care category mix of patients between individual hospitals. Medical deterioration in an underlying condition and family pressure on the general practitioner or carers' inability to cope each contributed to around half of all admissions. Of all admissions, 38% lived alone, and 18% of carers were disabled. Incontinence was reported for 35% of patients, and 26% of all patients were of a high nursing dependency. There was low utilization of community services before admission and 33% received none. There was variation between individual hospitals in use of local and district general hospital investigations, specialist referral and types of therapy. Of 685 admissions 11% died during their stay. Of those discharged, 76% went to their own or a relative's home, 10% to a residential or nursing home and 9% were transferred to an acute bed. Nine percent of discharges were postponed and 10% were brought forward. On discharge to non-residential care, 26% of patients received no community services. CONCLUSION. Shifting resources from secondary to primary care is a priority for purchasers. Both the introduction of the National Health Service and community care act 1990, and acute units having increasing incentives for earlier discharge, are likely to place greater demands on community hospital beds. Not all general practitioners have the option of community hospital beds. Before access to general practitioner beds can be broadened, existing beds should be used appropriately and shown to be cost-effective. Purchasers therefore require criteria for the appropriateness of admissions to general practitioner beds, and the results of a general practitioner bed cost-benefit analysis.     

Hospital services for patients with acute stroke in Ireland: the Volunteer Stroke Scheme survey of consultant opinion

A national postal survey of hospital based consultants with responsibility for acute care of stroke admissions was performed in November, December 1998. Of 162 survey forms, 140 (86.4%) were returned representing consultants working in all 38 acute general hospitals (total 10,067 hospital beds) of whom 135 indicated that stroke patients were admitted under their care. Patients were admitted under 11 different subspeciality groups to various medical and surgical wards. Only 18.5% of consultants worked in hospitals where there was a physician/neurologist with specific responsibility for stroke, whilst only 19.5% were aware of a policy in their hospital for implementation of minimum standards of care for stroke patients or a recent audit of stroke care (9%). A substantial number of hospitals in certain health board areas have no access to a consultant led rehabilitation unit within their own health board area whilst 18/38 hospitals have no on-site CT brain scanning. Despite the proven value of organised hospital stroke care, this survey documents major deficiencies in this country. We suggest that each health board would review its services to include in each hospital a consultant physician with special responsibility for co-ordination and development of appropriately staffed and funded stroke services.     

Estimating HIV prevalence and the impact of HIV/AIDS on a Ugandan hospital by combining serosurvey data and hospital discharge records

OBJECTIVE: To estimate the disease-specific HIV prevalence in a northern Ugandan hospital and to evaluate the impact of HIV/AIDS on hospital services. DESIGN: HIV serosurvey and analysis of routinely compiled hospital records. METHODS: The serosurvey was conducted among all 352 patients admitted to the medical ward of the Lacor Hospital in March 1999 (this ward consists of 3 units: general medicine, tuberculosis, and cancer). The impact on hospital services was estimated using the hospital discharge records for all 3447 patients admitted in 1999, in combination with serosurvey data, and was expressed as the percentage of bed-days attributable to HIV-positive patients. RESULTS: The overall HIV prevalence was 42.0% (52.6, 44.6, and 13.2% in the general medicine, tuberculosis, and cancer units, respectively). The disease-specific prevalence ranged from 45-65% for patients with tuberculosis, pneumonia, malaria, and enteritis. HIV-positive patients, compared with HIV-negative patients, had a higher in-hospital mortality (14.6 vs. 3.0%) and a lower average length of stay (41.4 vs. 48.9 days). AIDS cases accounted for 5.0% of hospital admissions, 4.1% of bed-days, and 11.5% of deaths. When considering all HIV-positive patients, these accounted for 37.2% of the bed-days. CONCLUSIONS: Knowledge of disease-specific HIV prevalence and of the patterns of HIV-related diseases is crucial for early case management. The impact of HIV-positive patients on hospital services is quite high, accounting for >1/3 of the bed-days in 1999. Providing a continuum of care through inpatient, outpatient, and outreach home care services probably represents the only means of relieving the pressure on overloaded hospitals.     

Casualty and surgical services in Perthshire general practitioner hospitals 1954-84

The results are reported of a study of casualty and surgical services in five general practitioner hospitals in Perthshire — Aberfeldy, Auchterarder, Blairgowrie, Crieff and Pitlochry. Details of the total workload, the nature of the conditions treated and the referral rate to major hospitals are given. Figures for the Royal Infirmary, Perth, the main referral hospital for the county, are also given for comparison. The surgical service at one of the rural hospitals is described.

Experience has demonstrated the usefulness of these hospitals in providing casualty and surgical services to both the local population and to visitors, and their superiority in providing these services over health centres because staff and beds are available 24 hours a day.

Rural general practitioner hospitals merit a continuing share of resources and bed allocation as they spare major hospitals surgical and medical work. The general practitioners serving the hospitals studied here undertook almost 40% of the total accident and emergency workload in the Perth and Kinross area of Scotland.

     

Medical-psychiatric service

Recently, some American general hospitals have organized medical-psychiatric units for patients with concomitant medical and psychiatric disorder. These services have attracted considerable interest for their psychosomatic features, namely the treatment of patients who require acute hospital care and cannot be managed adequately either in a standard psychiatric unit or in the medical-surgical wards of the general hospital. In due course, however, as often happens with innovations, the establishment of medical-psychiatric units has also come in for criticism and evaluation. Different models of medical-psychiatric services are discussed and compared.     

Arranging hospital admission for acutely ill patients: problems encountered by general practitioners.

BACKGROUND. Reports in the national press suggest that general practitioners in London are experiencing difficulties in securing hospital admission for their acutely ill patients. AIM. A study was undertaken to investigate the problems encountered by general practitioners in one family health services authority in south east London in arranging acute admissions to hospital. METHOD. A self-report questionnaire was completed by a sample of general practitioners every time an acute hospital admission was attempted. RESULTS. A total of 493 questionnaires were completed by 111 general practitioners over the 47-day study period. Problems during the hospital admission procedure were experienced in 171 (35%) of the cases reported, with 115 of the 537 telephone calls to a hospital (21%) resulting in a refusal to admit the patient to that particular hospital. The main problem reported was that of 'no beds available', an obstacle to admission that was more likely to be encountered if the patient was aged 75 years or over than if the patient was younger. CONCLUSION. In the light of the problems reported, possible changes to the current method of arranging acute admissions to hospital in London are discussed.     

The clinical impact of the COVID-19 pandemic on daily urological practice: first 3-month multicenter results from İstanbul

Background/aimThe aim of this paper was to determine the general tendencies of urology patients and effect of COVID-19 pandemic on daily urological practice at tertiary centers located in the most affected area in Turkey.Materials and methodsWe retrospectively analyzed the data of 39,677 patients (group 1) that applied to 6 different large-volume tertiary centers in İstanbul for outpatient consultation, surgery, or other procedures in the 3-month period between March 16 and June 14, 2020. The distribution of the number of patients who applied to subspecialty sections of urology outpatient clinics and inpatient services were recorded by weeks. That data was compared to data obtained from 145,247 patients that applied to the same centers in the same period of the previous year (group 2). The reflection of worldwide and Turkish COVID-19 case distribution on the daily urological practice was analyzed.Results There was a decrease in the number of patients in all subspecialty sections the in group 1 compared to group 2; however, there was a significant proportional increase in urooncology and general urology admissions. A decrease of approximately 75% was observed in the total number of surgeries (p < 0.001). We detected a negative correlation between the numbers of admission to all outpatient clinics and COVID-19 cases or deaths in Turkey (p < 0.05). The same negative correlation was present for all surgical procedures and consultations (p < 0.05). The multivariate linear regression analysis revealed that the number of cases in Turkey, and the number of deaths worldwide affect the number of outpatient clinic admissions (R2 = 0.38, p = 0.028) and urological surgery (R2 = 0.33, p = 0.020) in Turkey negatively. ConclusionThis novel pandemic has implications even for urology practice. Urological surgical procedures were more affected by COVID-19-related deaths in Turkey and worldwide. Outpatient admissions and urological surgeries decreased significantly by increasing COVID-19 case numbers in Turkey and worldwide deaths.     

Acute hospital discharges of patients with major disability: a review of patients admitted to a young disabled unit

The aim of this study was to describe a young disabled unit (YDU). These units are increasingly required to serve the needs of people with severe disabilities. Forty-two patients were included in the study; the age range was 22 to 61 years. Traumatic brain injury was the most common diagnosis on admission (13), followed by sub-arachnoid haemorrhage and non-haemorrhagic stroke (11) and non-traumatic brain injury (7). For people with severe acquired brain injuries, the course of neurological recovery often exceeds two years. The prognosis made in the acute hospital setting may need to be revised in the YDU when input from a multidisciplinary rehabilitation team enables patients to further their independence. YDUs need to have their own multidisciplinary team and sessional support from specialists in rehabilitation medicine to provide slow-stream rehabilitation. It is necessary to adequately resource all services for disabled people including inpatient and outpatient rehabilitation services, community services and YDUs. Step-down services without specialised neurological rehabilitation input may fail to achieve the full potential for patients transferred out of acute hospitals.     

Urological emergency admissions to a community hospital: a review

A one-year study was conducted on the impact of emergency admissions to the 125-bed Southwest Community Hospital in Atlanta, Georgia. During the study in 1979, 70 urological emergency room admissions were made, of which 44 (62.8 percent) were males and 26 (37.2 percent) were females. In comparison, 93 admissions were made directly from the private office. The study considered the timeliness of diagnosis and treatment, surgical procedures performed, impact on urological emergency room nursing and medical personnel, physician response to notification, cost containment, and implied legal ramifications and organization structure. Thus, an immediate close scrutiny of urological emergency admission at the nonuniversity affiliated Southwest Community Hospital was permitted.     

Appropriate place of death for cancer patients: views of general practitioners and hospital doctors.

BACKGROUND. The majority of cancer patients in the United Kingdom die in a National Health Service hospital, a setting that is contrary to the wishes of those patients expressing a preference to die elsewhere, for example at home or in a hospice. AIM. A study was undertaken to determine clinicians' views of the appropriate place of death for cancer patients and to examine factors leading to patients being admitted to a hospital specialist services unit where they died. METHOD. A questionnaire was sent to all general practitioners and hospital doctors who had cared for cancer patients who had died between May 1991 and April 1992 in a single health district. The appropriateness of the place of death, whether the patient was terminally ill, reasons for hospital admission and effect on management had different resources been available were determined. RESULTS. A total of 1022 deaths attributable to cancer were recorded for patients registered with general practitioners in the study area. Questionnaires were returned by general practitioners for 951 of the deaths (93%); hospital doctors returned questionnaires for 216 out of 268 patients (81%) who had been admitted to hospital under the care of a consultant. For deaths which had occurred at home, in a community hospital, residential/nursing home or Marie Curie hospice, the place of death was considered appropriate by general practitioners in over 92% of cases. For deaths in the hospital specialist services unit the place of death was considered probably or definitely appropriate by general practitioners in 83% of the 212 cases, but not appropriate in 17% of cases (P < 0.001 compared with all other settings). Hospital doctors considered 27% of deaths in the unit inappropriate. Significantly fewer cases fulfilled the criteria for terminal illness (death expected and palliative treatment commenced) according to general practitioners among those dying in the specialist services unit compared with deaths elsewhere (P < 0.001). The most common main reasons for admission to the specialist services unit were for investigation, because of difficult symptom control (apart from pain) and for curative/active treatment. General practitioners reported that management of between a sixth and a quarter of patients admitted to the specialist services unit would have been affected by the availability of 24-hour home cover, community hospital beds and a city-based hospice. Among the group of patients fulfilling the study criteria for terminal illness, the effect of other services on patient management would have been considerably higher. CONCLUSION. A greater proportion of cases where patients died from cancer in settings other than a specialist services unit were considered appropriate by general practitioners compared with deaths in a specialist services unit. For a considerable minority of patients, death in a specialist services unit was not considered appropriate by the general practitioners or by the hospital doctors. Improvements in local hospice facilities, community hospitals and community support would mean that a substantial proportion of hospital admissions could be avoided and thus cancer patients could die in more appropriate settings.     

Acute medicine in a general practitioner hospital

Admissions during 1980 to a hospital staffed by general practitioners are analysed. Almost all (94 per cent) were acute admissions. The mean length of stay was 11.7 days and the mean age of the patients 63.3 years, with 40 per cent of them under 65 years of age. Two thirds of the patients were discharged to their homes and only 7 per cent of patients spent more than four weeks in hospital. General practitioner hospitals have medical, social and economic advantages over large district hospitals for certain acutely ill patients and have an important role in primary medical care.     

Moving to a purpose built acute psychiatric unit on a general hospital site--does the new environment produce change for the better?

The environment of a hospital can have a significant impact on the experiences of patients. In March 2003 a new purpose built acute psychiatric admission unit opened on the site of Kilkenny General hospital, while the admission wards of the 2 local stand-alone psychiatric hospitals closed. We sought to compare admissions before and after the move, hypothesising that there would be lower levels of aggression, sedative prescribing and intoxicant abuse in the new unit. Details of 98 acute admissions that occurred during the first 3 months of 2002 were compared to 97 acute admissions that occurred during the first 3 months of 2004. Average daily diazepam and chlorpromazine equivalents were calculated for each patient. The Modified Overt Aggression Scale (MOAS) was used to compare levels of aggression. Compared to 2002 fewer patients left the hospital against medical advice in 2004 (OR 0.35, p = 0.027). Overall levels of aggression fell significantly (p = 0.001). Levels of benzodiazapine prescribing also fell (Mean diazepam daily dose 5.75 mg in 2002 versus 4.14 mg in 2004; p = 0.003). There were trends towards reductions in involuntary admissions, admissions of intoxicated people, patients abusing intoxicants in hospital and in antipsychotic prescribing. It is likely that the more pleasant, better designed and less stigmatising environment of the new unit together with the renewed energy and optimism of clinical staff contributed to the changes observed.     

Variations in time of hospital presentation for deliberate self-harm and their implications for clinical services

BACKGROUND: Variation in number, characteristics and management of deliberate self-harm (DSH) patients presenting to hospital during the 24-h cycle and day of the week may have implications for patient services. We have investigated how patient characteristics and clinical management of DSH episodes vary according to hour and day of presentation. METHODS: Time of presentation was studied in 5348 DSH patients who presented to a general hospital following 9101 episodes during a 6-year period. Patient characteristics were identified through routine clinical monitoring. RESULTS: Presentations varied markedly during the 24-h cycle, ranging from a peak between 8 pm and 3 am (average hourly rate of 6.6% of all episodes) to a low between 4 am and 10 am (1.4%). The majority (72.0%) occurred outside office hours. DSH associated with alcohol use and interpersonal problems was more frequent during the late evening or night, and at the weekend. A greater proportion of daytime presentations involved high suicide intent (although a larger number of high intent acts presented at other times), and more were admitted and assessed. LIMITATIONS: This study was based on DSH presentations to one hospital. Time and date of presentation and of psychosocial assessment, not time of DSH, were available for analysis. CONCLUSIONS: Peak times for DSH presentations are at night and the weekend, suggesting that specialist DSH services in general hospitals should be available 24 h a day, 7 days a week. Time of presentation should not be used as a proxy measure of suicide intent.     

Characteristics of Inpatient Care and Rehabilitation for Acute First-Ever Stroke Patients

Purpose

The purpose of this study was to analyze the status of inpatient care for acute first-ever stroke at three general hospitals in Korea to provide basic data and useful information on the development of comprehensive and systematic rehabilitation care for stroke patients.

Materials and Methods

This study conducted a retrospective complete enumeration survey of all acute first-ever stroke patients admitted to three distinct general hospitals for 2 years by reviewing medical records. Both ischemic and hemorrhagic strokes were included. Survey items included demographic data, risk factors, stroke type, state of rehabilitation treatment, discharge destination, and functional status at discharge.

Results

A total of 2159 patients were reviewed. The mean age was 61.5±14.4 years and the ratio of males to females was 1.23:1. Proportion of ischemic stroke comprised 54.9% and hemorrhagic stroke 45.1%. Early hospital mortality rate was 8.1%. Among these patients, 27.9% received rehabilitation consultation and 22.9% underwent inpatient rehabilitation treatment. The mean period from admission to rehabilitation consultation was 14.5 days. Only 12.9% of patients were transferred to a rehabilitation department and the mean period from onset to transfer was 23.4 days. Improvements in functional status were observed in the patients who had received inpatient rehabilitation treatment after acute stroke management.

Conclusion

Our analysis revealed that a relatively small portion of patients who suffered from an acute first-ever stroke received rehabilitation consultation and inpatient rehabilitation treatment. Thus, applying standardized clinical practice guidelines for post-acute rehabilitation care is needed to provide more effective and efficient rehabilitation services to patients with stroke.     

Outcome of stroke related admissions to a general hospital

In a prospective study of patients admitted to a general hospital, 43 patients with stroke were identified accounting for 3.9% of all medical admissions over a six month period. Of these, 23.2% died in hospital, whilst 46.5% were discharged to the community, and 30.3% to institutional care after a mean length of stay in hospital of 24.5 and 34 days respectively. At follow-up seven months following discharge, most patients were alive and still residing in the community or institution to which they had been discharged. The majority of survivors (57%) however, were severely handicapped, 37% of whom were resident with carers in the community. Our study emphasises the overly long stay of stroke patients in the acute hospital, and the high morbidity in survivors with consequent demand on institutional and community care services.     

End of an experiment: report from an inner city community hospital

Community hospitals are associated with the provision of health care in rural rather than urban areas. However, the urban community hospital can reduce the pressure on acute hospitals and decrease the isolation of community health workers. In 1982 a community hospital was established in an inner London health district. This paper examines the role and function of this hospital over a oneyear period in 1986-87 and makes comparisons with the hospital's first two years of operation. The problems identified in the initial evaluation, such as low bed occupancy and the limited participation by general practitioners in the area, were still present. It was found that there had been a decrease in the number of patients treated for musculoskeletal, nervous system and respiratory problems but an increase in circulatory disorders and injuries or poisoning. There was also a marked decrease in the percentage of acute admissions but an increase in admissions for convalescence, rehabilitation and carer relief. Following a severe financial crisis in the health district the hospital was closed temporarily in November 1987.     

MRSA-surveillance in Germany: data from the Antibiotic Resistance Surveillance System (ARS) and the mandatory surveillance of MRSA in blood

Data from the German Antibiotic Resistance Surveillance system (ARS) and statutory notification of methicillin-resistant Staphylococcus aureus (MRSA) in blood cultures are presented. ARS is a voluntary laboratory-based surveillance system providing resistance data of all clinical pathogens and sample types from hospitals and ambulatory care. Statutory notification includes MRSA detected in blood and cerebrospinal fluid by microbiological laboratories. Resistance data from 2008 to 2010 and MRSA-bacteraemia incidences from 2010 are presented. From 2008 to 2010, resistance data from 70,935 Staphylococcus aureus isolates were transferred to the national health institution. MRSA proportions in hospitals and outpatient care account for 19.2% and 10.6%, respectively. In hospital care high proportions of MRSA were found in nephrological, geriatric, neurological general wards and surgical ICUs (49.4%, 45.8%, 34.2%, and 27.0%, respectively), while in community outpatient care urological practices (29.2%) account for the highest values. In both healthcare settings urinary tract samples stand out with high proportions of MRSA (hospitals, 32.9%; outpatients, 20.5%). In 2010, 3900 cases of MRSA bacteraemia were reported, accounting for an incidence of MRSA bacteraemia of 4.8/100,000 inhabitants/year. Stratification by federal states shows considerable regional differences (range, 1.0-8.3/100,000 inhabitants/year). Vulnerable areas in hospitals and outpatient care have been pointed out as subjects for further inquiries.     

A qualitative study of why general practitioners admit to community hospitals.

BACKGROUND: Intermediate care, which is provided by community hospitals, is increasingly seen as one way of reducing pressure on secondary care. However, despite evidence of wide variation, there is little literature describing how general practitioners (GPs) use these hospitals. Because of the control they have over decisions to admit, development of these units depends on the cooperation of GPs. AIM: To identify and understand the factors influencing the decision to admit to a community hospital. DESIGN OF STUDY: A qualitative interview study. SETTING: Twenty-seven practitioners from ten practices supporting five community hospitals in one region of Tayside, Scotland Secondary support was identical for all sites. METHOD: In-depth interviews were conducted with a purposive sample of GPs representing those who had the most and the least use of the five community hospitals. A qualitative anaysis was performed to determine thefactors that practitioners considered important when making decisions about admission. Results were presented to the study group for validation. RESULTS: All admissions required adequate capacity in the community hospital system. Primarily social admissions were straight forward requiring only adequate hospital nursing, and GP capacity. More typical admissions involving social and medical needs required consideration of the professional concerns and the personal influences on the doctor as well as the potential benefits to the patient. As medical complexity increased the doctor's comfort/discomfort became the deciding factor. CONCLUSION: Provided there was adequate capacity, the GPs perceived the level of comfort to be the prime determinant of which patients are admitted to community hospitals and which are referred to secondary care.